Abstract
Though the rate of cesarean delivery in the USA decreased in the1980s, it once again increased substantially over the last 20 years and accounts for about one third of all deliveries. Reasons for this trend are numerous and include a decrease in the rate of trial of labor after cesarean (TOLAC) delivery and an increase in primary cesareans, mostly due to labor abnormalities or abnormal fetal heart rate tracings. On balance, cesareans are relatively safe, contributing to our collective comfort with increasing numbers of procedures. However, there is considerable ‘downstream’ morbidity associated with cesareans, especially in women who undergo multiple procedures. This review will address the short-term and long-term complications associated with multiple cesarean sections and will briefly identify strategies to reduce the rate of cesarean delivery.
Financial & competing interests disclosure
The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.
No writing assistance was utilized in the production of this manuscript.
Key issues
• Cesarean delivery rate has increased over the last two decades and accounts for approximately 30% of all deliveries in the USA. It is related to a multitude of reasons, including a decrease in the trial of labor after cesarean (TOLAC) rate and an increase in the primary cesarean rate.
• Placenta accreta is a disorder of abnormal placentation and is a complication of multiple cesarean sections. The risk of placenta accreta is increased even further in the setting of placenta previa. Placenta accreta disorder often requires peripartum hysterectomy and is associated with significant maternal morbidity.
• Multiple cesarean sections are associated with an increased risk of hysterectomy, intensive care unit (ICU) admission, need for blood transfusion and difficulty in delivering the neonate.
• Cesarean delivery has been associated with stillbirth and intrauterine growth restriction, however study results on this topic have been conflicting.
• Cesarean sections are known to cause chronic pain more commonly than vaginal deliveries. Risk factors for chronic pain after cesarean delivery include increased laterality of the incision, poor post-operative pain control, peritoneal closure, uterine exteriorization and general anesthesia during the procedure.
• Adhesive disease is a complication of multiple cesarean sections and is associated with a longer incision to delivery interval, increased operative time and bladder injury in future cesarean deliveries.
• Quality studies are lacking regarding the association of cesarean section with fertility, miscarriage and ectopic pregnancy; however, cesarean scar ectopic pregnancy is a known complication of previous cesarean delivery and its incidence is on the rise.
• Evaluating women for TOLAC candidacy, developing new technologies to evaluate intrapartum fetal well being, avoiding medically unnecessary inductions of labor and transitioning to an ‘accountable care’ system are some, but not all ways in which we can strive to decrease the cesarean section rate.
Notes
Data taken from Citation[32,33].